Ingunn Holden Bergh

Intervention effects on physical activity: the HEIA study - a cluster randomized controlled trial

BackgroundAlthough school-based interventions to promote physical activity in adolescents have been suggested in several recent reviews, questions have been raised regarding the effects of the strategies and the methodology applied and for whom the interventions are effective. The aim of the present study was to investigate effects of a school-based intervention program: the HEalth in Adolescents (HEIA) study, on change in physical activity, and furthermore, to explore whether potential effects varied by gender, weight status, initial physical activity level and parental education level.MethodsThis was a cluster randomized controlled 20 month intervention study which included 700 11-year-olds. Main outcome-variable was mean count per minute (cpm) derived from ActiGraph accelerometers (Model 7164/GT1M). Weight and height were measured objectively. Adolescents reported their pubertal status in a questionnaire and parents reported their education level on the consent form. Linear mixed models were used to test intervention effects and to account for the clustering effect of sampling by school.ResultsThe present study showed an intervention effect on overall physical activity at the level of p = 0.05 with a net effect of 50 cpm increase from baseline to post intervention in favour of the intervention group (95% CI −0.4, 100). Subgroup analyses showed that the effect appeared to be more profound among girls (Est 65 cpm, CI 5, 124, p = 0.03) and among participants in the low-activity group (Est 92 cpm, CI 41, 142, p < 0.001), as compared to boys and participants in the high-activity group, respectively. Furthermore, the intervention affected physical activity among the normal weight group more positively than among the overweight, and participants with parents having 13–16 years of education more positively than participants with parents having either a lower or higher number of years of education. The intervention seemed to succeed in reducing time spent sedentary among girls but not among boys.ConclusionsA comprehensive but feasible, multi-component school-based intervention can affect physical activity patterns in adolescents by increasing overall physical activity. This intervention effect seemed to be more profound in girls than boys, low-active adolescents compared to high-active adolescents, participants with normal weight compared to the overweight, and for participants with parents of middle education level as opposed to those with high and low education levels, respectively. An implementation of the HEIA intervention components in the school system may have a beneficial effect on public health by increasing overall physical activity among adolescents and possibly among girls and low-active adolescents in particular.

Are screen-based sedentary behaviors longitudinally associated with dietary behaviors and leisure-time physical activity in the transition into adolescence?

BackgroundThere is a need for more longitudinal studies investigating the associations between screen-based sedentary behaviors (SB), dietary behaviors and leisure-time physical activity (PA).MethodsIn the HEIA cohort study, 908 children were followed from age 11 to age 13 (September 2007 – May 2009). The children self-reported their intake of fruits, vegetables, soft drinks with sugar and snacks. TV/DVD use, computer/game use and leisure-time PA were also self-reported. Multilevel generalized linear mixed model analysis was used to assess longitudinal associations between the screen-based SB and each of the two other behaviors.ResultsTwenty-month changes in TV/DVD use and computer/game use were positively associated with changes in the consumption of soft drinks with sugar and unhealthy snacks in the same period; and inversely associated with change in vegetable consumption. Change in computer/game use was also inversely related to change in fruit consumption. An inverse but non-substantive association was found between change in TV/DVD use and change in leisure-time PA. Change in computer/game use was not significantly associated with change in leisure-time PA.ConclusionsChanges in screen-based SB were associated with multiple unfavorable changes in dietary habits, although the associations were weak. These associations need to be further investigated in intervention/experimental studies, to assess whether changing screen-based SB will result in clinically relevant changes in dietary behaviors. However, the findings of this study suggest that screen-based SB and leisure-time PA are largely independent behaviors which should be addressed separately in health promotion activities.

Design of a 20-month comprehensive, multicomponent school-based randomised trial to promote healthy weight development among 11-13 year olds: The HEalth In Adolescents study

Background and purpose: The lack of effective school-based interventions for preventing obesity in children has caused a call for longer duration of interventions and better reporting on design and evaluation methodology. The purpose of this paper is to present the development of the intervention, the design of the effectiveness study, and the test-retest reliability of the main outcome measures in the HEalth In Adolescents (HEIA) study. Methods/design: The HEIA intervention programme was developed based on literature reviews, a social ecological framework, and focus groups. The intervention aimed to increase total physical activity (PA) and consumption of fruit and vegetables and to decrease screen time and consumption of sugar-sweetened beverages. The intervention programme consisted of a classroom component, including dietary behaviour lessons, computer tailoring, fruit/vegetable and PA breaks, and posters, and an environmental component including active transport campaigns, equipment, suggestions for easy improvements of schoolyards, inspirational courses for teachers (all with regards to PA), and fact sheets to parents. The effect of the intervention programme is evaluated in a cluster randomised controlled trial design (intervention = 12 schools, control = 25 schools) including process evaluation. Main outcomes include anthropometry, PA, screen time, and consumption of fruit, vegetables, and sugar-sweetened beverages. A 2-week test— retest study was conducted among 114 pupils. Determinants of the behaviours were assessed. Similar data were collected from parents. Children’s PA was measured objectively by accelerometers. Conclusions: The HEIA study represents a theoretically informed randomised trial comprising a comprehensive set of multilevel intervention components with a thorough evaluation using reliable outcome measures. The study will contribute to a better understanding of determinants of healthy weight development among young people and how such determinants can be modified.

Personal and social-environmental correlates of objectively measured physical activity in Norwegian pre-adolescent children.

The aim of this study was to examine modifiable biological, psychological, behavioral and social‐environmental correlates of physical activity among 1129 Norwegian 11‐year‐old children within a cross‐sectional sample from the HEalth In Adolescents study. Physical activity was assessed by accelerometer, and weight and height were measured objectively. Age‐ and gender‐specific cut‐off points proposed by the International Obesity Task Force were used to define body mass index. Social‐environmental variables were self‐reported by questionnaire. Hierarchical regression (linear mixed models) revealed that normal weight children scored higher on percentage daily moderate‐to‐vigorous physical activity [% daily moderate to vigorous physical activity (MVPA)] than overweight/obese children (P<0.001). Self‐efficacy (P<0.01) and perceived social support from friends (P<0.01) were positively associated with childrens % daily MVPA, and a negative association was found for computer/game‐use on weekends (P<0.01). A moderator effect of weight category (normal vs overweight/obese) in the relationship between computer/game‐use on weekends and % daily MVPA was detected (P<0.05), reflecting that higher computer/game‐use on weekends was associated with lower % MVPA among the overweight/obese, but not among the normal weight. Modifiable correlates from multiple domains accounted for 14% of the variance in % daily MVPA. Prospective and intervention studies are needed to examine whether these factors act as mediators for physical activity change in pre‐adolescent children.

Stability and change in screen-based sedentary behaviours and associated factors among Norwegian children in the transition between childhood and adolescence

BackgroundIn order to inform interventions to prevent sedentariness, more longitudinal studies are needed focusing on stability and change over time in multiple sedentary behaviours. This paper investigates patterns of stability and change in TV/DVD use, computer/electronic game use and total screen time (TST) and factors associated with these patterns among Norwegian children in the transition between childhood and adolescence.MethodsThe baseline of this longitudinal study took place in September 2007 and included 975 students from 25 control schools of an intervention study, the HEalth In Adolescents (HEIA) study. The first follow-up took place in May 2008 and the second follow-up in May 2009, with 885 students participating at all time points (average age at baseline = 11.2, standard deviation ± 0.3). Time used for/spent on TV/DVD and computer/electronic games was self-reported, and a TST variable (hours/week) was computed. Tracking analyses based on absolute and rank measures, as well as regression analyses to assess factors associated with change in TST and with tracking high TST were conducted.ResultsTime spent on all sedentary behaviours investigated increased in both genders. Findings based on absolute and rank measures revealed a fair to moderate level of tracking over the 2 year period. High parental education was inversely related to an increase in TST among females. In males, self-efficacy related to barriers to physical activity and living with married or cohabitating parents were inversely related to an increase in TST. Factors associated with tracking high vs. low TST in the multinomial regression analyses were low self-efficacy and being of an ethnic minority background among females, and low self-efficacy, being overweight/obese and not living with married or cohabitating parents among males.ConclusionsUse of TV/DVD and computer/electronic games increased with age and tracked over time in this group of 11-13 year old Norwegian children. Interventions targeting these sedentary behaviours should thus be introduced early. The identified modifiable and non-modifiable factors associated with change in TST and tracking of high TST should be taken into consideration when planning such interventions.

Effects of a 20-month cluster randomised controlled school-based intervention trial on BMI of school-aged boys and girls: the HEIA study

Background School-based interventions that target prevention of overweight and obesity in children have been tested with mixed results. Thus, successful interventions are still called for. The aim of the present study was to investigate effects of a multicomponent school-based intervention programme targeting physical activity, sedentary and dietary behaviours on anthropometric outcomes. Methods A 20-month intervention was evaluated in a cluster randomised, controlled study of 1324 11-year-olds. Outcome variables were body mass index (BMI), BMI-for-age z-score (BMIz), waist circumference (WC), waist-to-height ratio (WTHR) and weight status (International Obesity Task Forces cut-offs). Weight, height and WC were measured objectively; pubertal status was self-reported and parental education was self-reported by the parents. Intervention effects were determined by one-way analysis of covariance and logistic regression, after checking for clustering effects of school, and moderating effects of gender, pubertal status and parental education. Results Beneficial effects were found for BMI (p=0.02) and BMIz (p=0.003) in girls, but not in boys. While a beneficial effect was found for BMI (p=0.03) in participants of parents reporting a high level of education, a negative effect was found for WTHR in participants with parents reporting a low level of education (p=0.003). There were no intervention effects for WC and weight status. Conclusions A multicomponent 20-month school-based intervention had a beneficial effect on BMI and BMIz in adolescent girls, but not in boys. Furthermore, children of higher educated parents seemed to benefit more from the intervention, and this needs attention in future interventions to avoid further increase in social inequalities in overweight and obesity.

Overweight and waist circumference among Norwegian 11-year-olds and associations with reported parental overweight and waist circumference: The HEIA study

Aims: The aim of this paper is to investigate anthropometric characteristics in 11-year-old Norwegian by gender and parental education, and to study associations between adolescents’ overweight and waist circumference (WC) and maternal and paternal overweight and WC. Methods: A total of 1483 adolescents, 1156 mothers, and 1016 fathers participated in the baseline survey of the HEalth In Adolescents (HEIA) study (September 2007). Anthropometric measures of the adolescents were assessed by project staff according to standard procedures. Self-reported data about pubertal status were collected through questionnaires. Parental education and anthropometric measures of parents were collected by self-report. Results: The prevalence of overweight (including obesity) determined by the cut-offs for body mass index (BMI) suggested by the International Obesity Task Force was 14.6% among girls and 13.6% among boys. The highest prevalence of overweight was observed among adolescents with parents who had less than 12 years of education (18.8%). Overweight and WC in girls was strongly associated with maternal overweight and WC. For boys, overweight and WC was strongly associated with both maternal and paternal overweight and WC. Conclusions: There was a social gradient in anthropometric characteristics and overweight rates among Norwegian 11-year-old adolescents. Maternal overweight and WC was associated with overweight and WC in girls and boys, while paternal overweight and WC were associated with overweight and WC in boys. The results indicate that mothers are key persons in prevention of overweight among adolescents, despite gender. Fathers are important as role models for their sons. Targeting parental overweight/ obesity could be a strategy in future interventions.

Mid-way and post-intervention effects on potential determinants of physical activity and sedentary behavior, results of the HEIA study - a multi-component school-based randomized trial

BackgroundThere is limited knowledge as to whether obesity prevention interventions are able to produce change in the determinants hypothesized to precede change in energy balance-related behaviors in young people. The aim of this study was to evaluate the effect of a multi-component intervention on a wide range of theoretically informed determinants of physical activity (PA) and sedentary behavior (SB). Moderation effects of gender, weight status and parental education level and whether the perceived intervention dose received influenced the effects were also explored.MethodsThe HEIA study was a 20-month school-based, randomized controlled trial to promote healthy weight development. In total, 1418 11-year-olds participated at baseline and post-intervention assessment. Enjoyment, self-efficacy, perceived social support from parents, teachers and friends related to PA, perceived parental regulation of TV-viewing and computer/game-use and perceived social inclusion at schools were examined by covariance analyses to assess overall effects and moderation by gender, weight status and parental education, mid-way and post-intervention. Covariance analyses were also used to examine the role of intervention dose received on change in the determinants.ResultsAt mid-way enjoyment (p = .03), perceived social support from teachers (p = .003) and self-efficacy (p = .05) were higher in the intervention group. Weight status moderated the effect on self-efficacy, with a positive effect observed among the normal weight only. At post-intervention results were sustained for social support from teachers (p = .001), while a negative effect was found for self-efficacy (p = .02). Weight status moderated the effect on enjoyment, with reduced enjoyment observed among the overweight. Moderation effects for parental education level were detected for perceived social support from parents and teachers. Finally, positive effects on several determinants were observed among those receiving a high as opposed to a low intervention dose.ConclusionThe intervention affected both psychological and social-environmental determinants. Results indicate that social support from teachers might be a potential mediator of PA change, and that overweight adolescents might be in need of specially targeted interventions to avoid reducing their enjoyment of PA. Further studies should continue to assess how intervention effectiveness is influenced by the participants’ self-reported dose of intervention received.

Correlates of weight status among Norwegian 11-year-olds: The HEIA study

BackgroundThe underlying mechanisms of overweight and obesity in adolescents are still not fully understood. The aim of this study was to investigate modifiable and non-modifiable correlates of weight status among 1103 Norwegian 11-year-old adolescents in the HEalth in Adolescents (HEIA) study, including demographic factors such as gender and parental education, and behavioral factors such as intake of sugar-sweetened beverages, snacks and breakfast consumption, watching TV and playing computer games, physical activity and sedentary time.MethodsWeight and height were measured objectively, body mass index (BMI) was calculated and International Obesity Task Force cut-offs were used to define weight status. Physical activity and sedentary time were measured by accelerometers. Other behavioral correlates and pubertal status were self-reported by questionnaires. Parental education was reported by the parents on the consent form for their child. Associations were investigated using logistic regressions.ResultsThere were gender differences in behavioral correlates of weight status but not for weight status itself. Adolescents with parents in the highest education category had a 46% reduced odds of being overweight compared to adolescents with parents in the lowest education category. Adolescents with parents with medium education had 42% lower odds of being overweight than adolescents with parents with the lowest education category. Level of parental education, breakfast consumption and moderate to vigorous physical activity were positively associated with being normal weight, and time watching TV was positively associated with being overweight for the total sample. Gender differences were detected; boys had a doubled risk of being overweight for every additional hour of watching TV per week, while for girls there was no association.ConclusionsThe present study showed a social gradient in weight status in 11-year-olds. Both breakfast consumption and moderate to vigorous physical activity were inversely associated with weight status. No associations were found between intake of sugar-sweetened beverages and snacks, playing computer games and weight status. Watching TV was positively associated with weight status for boys but not for girls. Interventions are needed to gain more insight into the correlates of change in weight status.

Does the school food environment influence the dietary behaviours of Norwegian 11-year-olds? The HEIA study

Aims: The aim of the study is to investigate the influence of the school food environment on the dietary behaviours of 11-year-old Norwegian children in elementary schools. Methods: Baseline data from a school-based intervention study: the Health In Adolescents study was used. A total of 1425 11-year-old children from 35 schools from the eastern part of Norway were included. School administrators provided information on the physical, political, and sociocultural school food environment and students reported their intake of fruits, vegetables, sugar-sweetened beverages (SSB), and snacks. Multilevel modelling was used to assess the school-level variance in dietary behaviours and to investigate the association of school food environmental factors with these dietary behaviours. Results: After adjustment for student characteristics, the school level accounted for a small proportion (1.1%–3.0%) of the variance in the dietary behaviours investigated. None of the investigated school food environmental factors were found to be related to the children’s reported intake of fruits, vegetables, snacks or SSB. Conclusions: Most of the variance in the dietary behaviours investigated was at the personal level. Thus in this sample, the investigated school-level factors do not appear to exert a strong influence on the dietary behaviours of children. Longitudinal studies using validated measures of the school food environment are needed.